Gonococcal pharyngitis is an infection of the throat caused by the bacterium Neisseria gonorrhoeae. It is a sexually transmitted infection (STI) that can lead to significant morbidity if left untreated. Accurate coding with ICD-10 Code A54.5 is essential for proper diagnosis, documentation, medical billing, and public health reporting, ensuring that healthcare providers can effectively manage and track this condition.
What is ICD-10 Code A54.5 for Gonococcal pharyngitis?
ICD-10 Code A54.5 specifically represents Gonococcal pharyngitis, an infection of the pharynx caused by Neisseria gonorrhoeae. This code should be used in clinical documentation and billing when a patient presents with symptoms indicative of this condition, such as sore throat or dysphagia, and is confirmed through appropriate testing.
ICD-10 Code A54.5 – Clinical Definition and Explanation of Gonococcal pharyngitis
Gonococcal pharyngitis is primarily caused by the transmission of Neisseria gonorrhoeae during oral sexual contact. The condition can progress to more severe complications if not treated promptly, necessitating medical attention. Early diagnosis and treatment are crucial to prevent further transmission and complications.
Key Clinical Features:
- Sore throat and difficulty swallowing
- Purulent discharge from the throat
- Fever and systemic symptoms
- History of recent sexual contact with an infected partner
ICD-10 Code A54.5 for Gonococcal pharyngitis – SOAP Notes & Clinical Use
ICD-10 Code A54.5 is utilized in SOAP notes to document the patient's symptoms, assessment findings, and treatment plan for Gonococcal pharyngitis. This code is relevant in both acute and chronic care settings, ensuring comprehensive documentation of the patient's condition.
What Does ICD-10 Code A54.5 for Gonococcal pharyngitis Mean in SOAP Notes?
In SOAP notes, ICD-10 Code A54.5 connects subjective patient-reported symptoms and objective clinical findings to a formal diagnosis of Gonococcal pharyngitis. This ensures continuity of care, supports accurate billing, and meets EHR documentation standards.
Treatment Options for ICD-10 Code A54.5 – Gonococcal pharyngitis
Gonococcal pharyngitis requires prompt treatment to prevent complications and transmission. Hospitalization may be necessary in severe cases, and appropriate antibiotic therapy is critical.
Antibiotic Therapy:
- Ceftriaxone 250 mg IM once
- Azithromycin 1 g orally once (alternative)
- Doxycycline 100 mg orally twice daily for 7 days (alternative)
Supportive Care:
- Hydration and rest
- Analgesics for pain relief
- Throat lozenges to soothe irritation
Infection Control:
- Educate patients on safe sexual practices
- Advise on notifying sexual partners
- Implement precautions during outbreaks
How to Document Symptoms of Gonococcal pharyngitis (ICD-10 A54.5) in SOAP Notes
Subjective:
- Patient reports sore throat for 3 days
- History of unprotected oral sex with a new partner
- Complains of fever and malaise
- Denies cough or nasal congestion
Objective:
- Throat examination reveals erythema and exudate
- Temperature 101°F
- Lymphadenopathy noted in cervical region
- Positive throat culture for Neisseria gonorrhoeae
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SOAP Note Guidelines for Diagnosing Gonococcal pharyngitis (ICD-10 Code A54.5)
Assessment:
- Diagnosis: Gonococcal pharyngitis, moderate severity
- ICD-10 Code: A54.5
- Contributing factors: Recent sexual activity with an infected partner
- No known drug allergies
Plan:
- Initiate treatment with Ceftriaxone 250 mg IM
- Educate patient on STI prevention
- Schedule follow-up in one week to reassess symptoms
- Advise on partner notification and testing
Treatment & Plan Section for ICD-10 Code A54.5 – Gonococcal pharyngitis
- First-line treatment with Ceftriaxone and Azithromycin
- Encourage safe sexual practices to prevent recurrence
- Monitor for treatment response and potential complications
- Follow-up appointments to ensure resolution of symptoms
Using ICD-10 Code A54.5 for Gonococcal pharyngitis in Billing & SOAP Note Compliance
- Ensure accurate documentation of symptoms and treatment in SOAP notes
- Use A54.5 for billing when Gonococcal pharyngitis is diagnosed
- Document any complications or related conditions for comprehensive coding
- Align treatment plans with clinical guidelines for justified billing
Related ICD-10 Codes Often Used with Gonococcal pharyngitis
- A54.0 – Gonococcal infection of the lower genitourinary tract
- A54.1 – Gonococcal infection of the rectum
- A54.2 – Gonococcal infection of the eye
- A54.3 – Gonococcal infection of the pharynx
- A54.9 – Gonococcal infection, unspecified
ICD-10 Code A54.5 in Medical Billing and Insurance for Gonococcal pharyngitis
ICD-10 Code A54.5 is critical in medical billing, particularly in hospital, ER, or infectious disease care settings.
Billing Notes:
- Document all relevant symptoms and history to support the diagnosis
- Use A54.5 in conjunction with other codes for comprehensive billing
- Ensure that treatment plans are clearly outlined in the medical record
Common CPT Pairings:
| CPT Code | Description |
|---|---|
| 99213 | Established patient office visit, low complexity |
| 87070 | Culture, bacterial, any source, positive identification |
| 36415 | Collection of venous blood by venipuncture |
| 87491 | Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique |
Frequently Asked Questions
Common Questions About Using ICD-10 Code A54.5 for Gonococcal pharyngitis
What are the common symptoms of Gonococcal pharyngitis?
Common symptoms include a sore throat, difficulty swallowing, fever, and purulent discharge. Patients may also experience systemic symptoms such as malaise and lymphadenopathy.
How is Gonococcal pharyngitis diagnosed?
Diagnosis is typically confirmed through a throat culture or nucleic acid amplification tests (NAAT) that detect Neisseria gonorrhoeae. Clinical history and symptomatology also play a crucial role.
What is the recommended treatment for Gonococcal pharyngitis?
First-line treatment includes Ceftriaxone 250 mg IM and Azithromycin 1 g orally. Alternative regimens may be considered based on patient history and allergies.
Is Gonococcal pharyngitis contagious?
Yes, Gonococcal pharyngitis is contagious and can be transmitted through oral sexual contact. Safe sexual practices are essential to prevent transmission.
